Question

Donald has been diagnosed with a malignant tumor in his liver that contained cells from his bladder. Imagine you need to construct a communication memo to his insurance company to argue a rejected claim for the diagnostic procedures. Describe what terms would you use and how the application of medical terminology could be a major factor in whether or not the claim is paid. What other information would be helpful in this case?

a) ICD-10 codes
b) CPT codes
c) Malignant tumor grading
d) Radiological imaging techniques

Answer 1

To appeal a rejected insurance claim for diagnostic procedures of a malignant tumor, the memo should include ICD-10 codes for diagnosis, CPT codes for the procedures performed, details on malignant tumor grading, and an explanation of the radiological imaging techniques used. Additional supportive information may include patient history, condition progression, and previous treatments.

Step-by-step explanation:

In the case of Donald's rejected insurance claim for diagnostic procedures of a malignant tumor with bladder cells in the liver, specific terminology and coding are crucial for successful communication and reimbursement. The communication memo to the insurance company should include the following terms:

• ICD-10 codes: Provide the exact diagnosis codes that correspond to the patient's condition. These codes are essential for the insurance company to identify and verify that the diagnostic procedures performed were necessary for that specific condition.
• CPT codes: Include the Current Procedural Terminology codes that describe every step of the diagnostic procedures performed. This assists the insurance company in understanding the services provided.
• Malignant tumor grading: Detail the grading of the tumor, as it can affect the urgency and type of treatment required, which can influence coverage decisions.
• Use of radiological imaging techniques: Explain the imaging techniques used to identify and diagnose the tumor, and how they were crucial in the diagnosis.

Other additional information that would be helpful could include patient history, progression of the illness, and any prior treatments. All this combined clarifies why the diagnostics were medically necessary.

For instance, the use of a biopsy to confirm the cancer diagnosis is a critical step since it determines the exact type and stage of cancer. Moreover, discussing the role of an interventional radiologist in managing such complex cases reinforces the need for precise diagnostics.